Ethnicity, socio-economic position and gender—do they affect reported health—care seeking behaviour?
Introduction
There are marked socio-economic gradients for mortality and morbidity, which appear to have worsened over the last few decades (Davey Smith, Bartley, & Blane, 1990; Shaw, Dorling, Gordon, & Davey Smith, 1999). Although it has been argued that health care systems do little to reduce the incidence of health inequalities (Mackenbach, Stronks, & Kunst, 1989; McKeown, Record, & Turner, 1975), there is growing evidence that newer medical technologies can have a major positive impact on life expectancy, case fatality and quality of life (Bunker, Frazier, & Mosteller, 1995; Goldman & Cook, 1984; Tunstall-Pedoe et al., 2000).
While the pursuit of equity of access to health care is a central objective of many health care systems, there is evidence that, although often in greater need, patients of ethnic minority descent or in lower socio-economic position (SEP) are less likely than Whites and more affluent groups, to access secondary and tertiary medical care. This is found both in the UK and USA, despite the NHS in the UK with services free at the point of delivery, and Medicare coverage in the US. Inequalities appear to be particularly prevalent in cardiac treatments (Ayanian, Udvarhelyi, Gatsonis, Pashos, & Epstein, 1993; Ben-Shlomo & Chaturvedi, 1995; Payne & Saul, 1997; Schneider, Zaslavsky, & Epstein, 2002; Whittle, Conigliaro, Good, & Lofgren, 1993), affecting both long-term survival (Whittle et al., 1993) and mortality (Peterson et al., 1997). Similarly, there is evidence to suggest gender inequality in treatment for heart disease, in particular, the under investigation and treatment of women in secondary and tertiary care (Dong, Colhoun, Ben-Shlomo, & Chaturvedi, 1996; Jackson, 1994; Mark, 2000).
Such inequity is not limited to cardiac services. For example, Black people have also been shown to have poorer survival rates for breast cancer than Whites (Bassett & Krieger, 1986), and lower SEP has been associated with later detection of breast cancer and thus preventable deaths (Farley & Flannery, 1989).
These findings increase in significance when compared to the (albeit) limited evidence which suggests that utilisation of primary care services among Black individuals and those from lower socio-economic groups is either equivalent, if not higher, than their White or more well off counterparts after adjustment for crude measures of need (Goddard & Smith, 2001; Haynes, 1991).
A number of possible reasons for such disparities have been suggested, including systematic differences by ethnicity and SEP in (a) interpretation of symptoms and recognition of the importance of receiving early intervention; (b) seeking health care; (c) obtaining a correct primary care diagnosis; (d) referral for specialist treatment, and (e) management at a specialist level. In this study we focused on (a) and (b). Our aim was to investigate the influence of ethnicity and socio-economic position on the perception of urgency in seeking health care in a cross-sectional survey, using responses to case-vignettes and health-care-seeking intentions for an episode of chest pain or a lump discovered in the axilla—both areas known to suffer inequalities in access to health care according to socio-economic position and ethnicity. The division of one vignette into two parts enabled us to examine whether behaviour evolved as symptoms changed. In this way, we have investigated the suggestion that patients of Black ethnicity and lower socio-economic position may receive less specialist care as a result of unwillingness to seek health care or ‘inappropriate’ interpretation of symptoms.
Section snippets
Methods
A total sample of 2500 individuals, aged between 18 and 75 years were selected from two primary care practices in the South West of England. The practices were chosen because they included the range of socio-economic backgrounds and a substantial number of Black1 individuals. A sample of 1500 randomly selected from one practice and 500, stratified by ethnicity, from the other were
Results
The questionnaire was posted to 2500 people within two General Practices, but contact details were inaccurate for 461. Out of an effective sample size of 2039, 1350 completed questionnaires were returned (response rate 66%). Table 1 shows the characteristics of the study sample.
Discussion
Previous work clearly indicates that inequalities in access to secondary and tertiary health care exist, but it is unclear at which points in the chain of events leading from perception of need through attendance at primary/emergency care, to referral and receipt of secondary care, inequalities occur. This study focused on the patient and his/her first action by using standardised case vignettes for two contrasting clinical scenarios to determine responses by socio-economic position, ethnicity
Acknowledgements
The research was funded by the UK South and West NHS Research and Development Directorate. The authors would like to express our gratitude to the respondents who took the time to complete the postal questionnaire. We would also like to thank the anonymous reviewers for their comments on the paper. Bristol is the lead centre of the MRC HSRC.
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